Can a percutaneous, extra-articular distal first ray osteotomy have an impact for mild and moderate bunion deformities? A recent study in the Journal of Foot and Ankle Surgery involving 217 feet (including 28 simultaneous bilateral cases) says this technique facilitates immediate postoperative weightbearing, minimal complications, reproducible results and application toward both the intermetatarsal and hallux abductus angles.
Noman Siddiqui, DPM, MHA, AACFAS, the lead author of the study, relates that prior to this study, his experience with minimally invasive surgery (MIS) was primarily minimal open approaches to ankle fusions, supramalleolar osteotomies, calcaneal osteotomies and corticotomy for limb lengthening among others. He explains that he was interested in applying those same principles to bunions after reading a 2005 article by Magnan and colleagues.
Dr. Siddiqui relates his technique in this study differs from that of Magnan and coworkers in that he wanted to incorporate the corticotomy method popularized by Ilizarov, making multiple small drill holes and connecting them with an osteotome. Specifically, he says that he wanted to use instrumentation, such as a Crile hemostat, which can be found in most, if not all, ORs in the United States. Magnan and colleagues utilized a Bosch device, which is grooved to guide the K-wire into the medullary canal.
“I wanted to use a regular hemostat so U.S. surgeons wouldn’t feel intimidated by not having a grooved device. I also avoided the use of a high-speed burr as it had a negative history with podiatric surgeons,” states Dr. Siddiqui, the Director of Podiatric Surgery and the Deformity Correction and Orthoplastics Fellowship at the Rubin Institute for Advanced Orthopedics/International Center for Limb Lengthening in Baltimore
Hummira Abawi, DPM, who was trained in percutaneous bunion correction by Dr. Siddiqui, currently uses a similar technique for all of her bunion procedures that do not exhibit significant hypermobility. She shares that she will typically use one K-wire and one internal screw for fixation.
The study authors conclude that perhaps a better term for this particular technique of MIS bunion correction could be “precision bunion surgery.” Drs. Abawi and Siddiqui agree.
“Precision incision surgery (PIS) is the ‘precise’ name for this technique. Making the incision precisely in line with the osteotomy ensures accuracy and allows for reproducible results,” explains Dr. Abawi, an Instructor of Orthopaedics with the University of Maryland School of Medicine.
Dr. Siddiqui provides further history on the use of this term, explaining that MIS surgery is traditionally viewed as “blind” surgery. He disagrees, explaining that the incised anatomy is simply more precise in this case.
“The osteotomy is precisely made at the metaphyseal-diaphyseal junction, which has better healing potential in comparison to a more cortical diaphysis. The osteotomy is extracapsular and the dissection is focused and limited to dorsal periosteal elevation. This provides better soft tissue stability, vascularity and healing,” explains Dr. Siddiqui, the Chief of Podiatry at Northwest Hospital in Randallstown, Md.
He also points out that the multiple drill hole method allows for a low-energy osteotomy and prevents thermal injury.
Dr. Abawi would like to see similar studies in the future look at various stages of bunion deformity, comparing outcomes with precision incision surgery, long-term studies to assess functional improvements, and a multicenter study comparing outcomes between precision incision surgery and the Lapiplasty procedure.
Dr. Siddiqui also feels future evaluation of patient satisfaction is important along with comparison with other methods.
He points out that this study is the first North American paper showing data consistent with that of European and Asian colleagues. Although four surgeons in four different locations produced similar results, Dr. Siddiqui says more long-term results are needed.
“We are working on that and have other studies looking at outcomes, satisfaction, pitfalls and other topics of interest,” adds Dr. Siddiqui.
What Is The Role Of Primary Deltoid Ligament Repair In Acute Ankle Fractures?
By Jennifer Spector, DPM, FACFAS, Associate Editor
Patients who had primary deltoid ligament repair as part of treatment for an acute ankle fracture showed superior radiological correction of the medial clear space and better pain scores than those that did not, according to a recent study in International Orthopaedics. However, functional outcomes and complication rates did not show significant differences in the 192 patients studied in this meta-analysis.
Jeffrey E. McAlister, DPM, FACFAS shares that in his experience, acute deltoid ligament injuries are often not discovered until much later in the patient experience.
“I see late diastasis or medial clear space gapping at least three to five years out from the index injury or procedure,” explains Dr. McAlister, a fellowship-trained foot and ankle surgeon, who is in private practice in Phoenix.
Citing excellent results from repairing the superficial deltoid acutely that include early range of motion and ankle rehabilitation, Dr. McAlister states that patients suffering from an unfixed deltoid complex can experience distal lateral tibial necrosis or lateral subluxation of the talus on the tibia. He says his standard protocol for repair of a bimalleolar ankle fracture is to repair the fibula, stress the syndesmosis and repair if necessary, and then stress evert the talus. If there is increased valgus tilt or stress greater than 10 degrees, Dr. McAlister will repair the deltoid with two anchors at the medial malleolus and medial talus.
Although the study did not show any differences in functional outcome or complications between patients with and without deltoid ligament repair, Dr. McAlister emphasizes focusing on the anatomy.
“The primary reason for repairing the deltoid is to restore functional anatomy. We all know the consequences of a poorly aligned ankle joint. Why not repair what’s broken? I only fix the deltoid if the stress eversion test is still positive after a syndesmotic repair,” explains Dr. McAlister. “This study highlights the incongruencies we still have in foot and ankle surgery. We don’t yet understand the long-term sequelae of fixing (the deltoid ligament) but we do know what happens when you do not fix it.”
Evaluating Laser Treatment As An Option For DFUs
By Jennifer Spector, DPM, FACFAS, Associate Editor
Could Erbium:YAG laser therapy accelerate wound healing in recalcitrant DFUs? A recently published Journal of Foot and Ankle Surgery study looked at 22 ulcers that were not responsive to standard care over four weeks. After four weeks of weekly laser treatment, the study authors noted wound area reduction averaged 63.4 percent and at 12 weeks, 50 percent of the wounds healed.
“Our results demonstrated that the response of the wounds included in the study were very good at four weeks follow-up,” states Javier La Fontaine, DPM, MS, a co-author of the study. “I think the fact that the Erbium laser is ablative might be adopted to the accepted debridement protocols recommending that chronic wounds be debrided every one to two weeks.”
David G. Armstrong, DPM, MD, PhD says the Erbium:YAG laser, like many alternative energy sources, seems to show some promise in either cleaning up a wound or stimulating the wound matrix.
When discussing the Erbium:YAG laser versus a Nd:YAG laser for wounds, a key advantage for the Erbium laser is once a week treatment, notes Dr. La Fontaine, a Professor in the Department of Plastic Surgery at the University of Texas Southwestern Medical Center. He adds that three times a week, as necessitated by the Nd:YAG laser, may not be realistic for patients logistically or financially due to copays.
Dr. Armstrong, a Professor of Surgery at the Keck School of Medicine at the University of Southern California, shares that a challenge the Erbium:YAG laser faces in the average limb preservation or wound healing clinic is speed.
“(These sites) will have demands on time and motion that many light-, energy- and ultrasound-based tools can’t yet deliver,” explains Dr. Armstrong. “That said, we remain very optimistic.”
Dr. La Fontaine feels those evaluating the study will see the Erbium:YAG laser as a viable alternative treatment for DFUs that are difficult to heal. He also states that future randomized controlled trials would be helpful to investigate long-term benefits of this treatment.